Creation of an Inflammatory Bowel Disease Referral Pathway for Identifying Patients Who Would Benefit From Inflammatory Bowel Disease Specialist Consultation.

BACKGROUND: Recommendations regarding signs and symptoms that should prompt referral of patients with inflammatory bowel disease (IBD) to an IBD specialist for a consultation could serve to improve the quality of care for these patients. Our aim was to develop a consult care pathway consisting of clinical features related to IBD that should prompt appropriate consultation. METHODS: A scoping literature review was performed to identify clinical features that should prompt consultation with an IBD specialist. A panel of 11 experts was convened over 4 meetings to develop a consult care pathway using the RAND/UCLA Appropriateness Method. Items identified via scoping review were ranked and were divided into major and minor criteria. Additionally, a literature and panel review was conducted assessing potential barriers and facilitators to implementing the consult care pathway. RESULTS: Of 43 features assessed, 13 were included in the care pathway as major criteria and 15 were included as minor criteria. Experts agreed that stratification into major criteria and minor criteria was appropriate and that 1 major or 2 or more minor criteria should be required to consider consultation. The greatest barrier to implementation was considered to be organizational resource allocation, while endorsements by national gastroenterology and general medicine societies were considered to be the strongest facilitator. CONCLUSIONS: This novel referral care pathway identifies key criteria that could be used to triage patients with IBD who would benefit from IBD specialist consultation. Future research will be required to validate these findings and assess the impact of implementing this pathway in routine IBD-related care.

This study aimed to develop a care pathway consisting of clinical features that should prompt inflammatory bowel disease expert consultation. A scoping literature review was performed to identify attributes, and an expert panel finalized the structure and components of the pathway.

Medical practice integration: going big in private practice.

Historically, gastroenterologists entered into solo, small group, or academic practices. The current economic environment and looming regulatory mandates have led to gastroenterologists integrating into large, single-specialty groups to acquire costly practice infrastructure, gain negotiating leverage with health plans, promote high-quality care, and benefit from professional practice management. Individual gastroenterologists must assess whether a large practice will meet their personal goals, financial needs, and professional visions. The decision to integrate into a large practice will also be affected by local practice patterns and regulatory issues. For these and other reasons, gastroenterologists are going big in private practice.

Gallbladder Polyps.

Most small gallbladder polyps are benign and do not change significantly over time. They are usually incidental findings on ultrasound. Therefore, these polyps should be checked periodically with routine percutaneous ultrasonography. In the asymptomatic patient, gallbladder polyps that are greater than 1 cm in diameter should be treated with cholecystectomy. The size of the polyp and the patient greater than 50 years are important risk factors for malignant potential. Patients who have biliary pain and small gallbladder polyps without gallstones present a difficult management decision for the clinician. If the physician is confident that the polyps are the source of the pain, patients should be referred for cholecystectomy. Endoscopic ultrasound and positron emission tomography may prove to be useful in assessing the malignant potential of large gallbladder polyps. Laparoscopic cholecystectomy is the treatment of choice for most gallbladder polyps. If a malignant polyp is suspected, patients should undergo an open cholecystectomy.